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Editorial Commentary: Return to Sport Following Extra-Articular Augmentation of Anterior Cruciate Ligament Reconstruction—Let the LET (Lateral Extra-Articular Tenodesis) Games Commence!

      Abstract

      The debate around extra-articular augmentation (EA) of anterior cruciate ligament (ACL) reconstruction continues to provide a rich source of research articles that we ultimately hope will improve patient outcomes. When combined with ACL reconstruction, anterolateral ligament reconstruction or lateral extra-articular tenodesis procedures reduce graft failure and persistent rotatory laxity. An important metric of ACL reconstruction outcome is return to play (RTP). RTP rates are also excellent when EA procedures are used in both primary and revision ACL reconstruction. However, when it comes to RTP, EA augmentation has yet to show significant improvement over isolated ACL reconstruction.
      You would have to have been isolated on a desert island with no communication with the outside world to have missed the biggest debate in sports knee surgery in the past decade. Does the anterolateral ligament (ALL) exist and does extra-articular augmentation (EA) of anterior cruciate ligament reconstruction (ACLR) improve patient outcomes? Thankfully, we are witnessing a reduction in the hyperbole that has followed some of the original articles and a greater emphasis has been placed on solid research and presentation of data. Although the interpretation of such data must be thoroughly critiqued, it at least provides a more robust platform to discuss the merits of this highly controversial procedure that many have now adopted into their clinical practice while others still continue to discount.
      The focus has finally moved away from “does the ALL exist?” to “which patients benefit most from an EA procedure?”
      • Rossi M.J.
      Editorial Commentary: Anterolateral ligament augmentation for the anterior cruciate ligament-deficient knee debate—the proof is in the pudding.
      However, even that is not free of controversy, with ongoing discussion and articles aiming to determine which EA procedure is most efficacious. Putting the often-contentious debates aside, we have seen in recently performed studies that both ALL reconstruction-
      • Sonnery-Cottet B.
      • Saithna A.
      • Cavalier M.
      • et al.
      Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI Study Group.
      and lateral extra-articular tenodesis (LET)
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial.
      -type procedures have been very effective in reducing graft failure and persistent rotatory laxity, confirming what systematic reviews and meta-analyses of past studies had previously found.
      • Devitt B.M.
      • Bell S.W.
      • Ardern C.L.
      • et al.
      The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: A systematic review with meta-analysis and best-evidence synthesis.
      • Hewison C.E.
      • Tran M.N.
      • Kaniki N.
      • Remtulla A.
      • Bryant D.
      • Getgood A.M.
      Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: A systematic review of the literature.
      • Song G.Y.
      • Hong L.
      • Zhang H.
      • Zhang J.
      • Li Y.
      • Feng H.
      Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon.
      But what is new about this work? The major difference is that we are now focusing on large prospective studies, both randomized and nonrandomized, with appropriate statistical power to answer specific important questions, such as clinical failure or graft failure.
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial.
      Furthermore, we are able to focus on the secondary questions, where maybe past studies have been unsuccessful in answering because of lack of numbers. Yes, EA of ACLR, in one form or another, works. However, is there a specific subpopulation of patients in whom an EA works best? Can preoperative morphologic characteristics predict those who may benefit from EA? Are there any downsides, either in the short or long term? Can graft choice mitigate the reduced risk of failure seen with the addition of LET (future Stability 2 randomized controlled trial will aim to answer this question)? Is EA of ACLR cost-effective? Does it result in improved function and performance? It is this latter question that is often the most important to consider, as based on a currently unpublished survey performed in our clinic, this seems to be the most important issue for our patients. After all, in most cases of ACLR, we aim to return our patients to their preinjury level of performance.
      As such, I read with great interest the article “Return to Play Following Anterior Cruciate Ligament Reconstruction With Extra-Articular Augmentation: A Systematic Review.”
      • Hurley E.T.
      • Manjunath A.K.
      • Strauss E.J.
      • Jazrawi L.M.
      • Alaia M.J.
      Return to play following anterior cruciate ligament reconstruction with extra-articular augmentation: A systematic review.
      performed by authors Hurley, Manjunath, Strauss, Jazrawi, and Alaia. I would like to congratulate the authors for performing a methodologically rigorous review with the aim of answering a very important question: Does EA of primary or revision ACLR result in similar or better rates of return to play (RTP) compared with ACLR alone? Following screening 1311 papers, a total of 19 studies were evaluated and data extracted. A mixture of level of evidence comparative studies of primary and revision ACLR with or without an EA procedure were included with both level of play and criteria for RTP investigated.
      The study found that high levels of RTP were found in both primary (82%-100%) and revision (50%-88%) ACLR when augmented with an extra-articular procedure; however, there were no differences in the RTP rates when an EA procedure was performed compared with when an ACLR was performed in isolation.
      At face value, this would suggest that the addition of an EA has little beneficial effect on subsequent return to sport, i.e., EA does not seem to improve athletic ability, nor does it hinder function.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability study.
      However, there are multiple issues with investigating return to sport in the literature. The first, and likely the most problematic, is the definition of return and how this is documented. When thinking of RTP, does this mean return to training, participation at a lower level, participation at same or higher level at a limited amount of time, or return to full competition? Anecdotally, we see our athletes return to play, but it often takes the following season to when they are able to be more competitive and play full games with little down time. As such, a measure of exposure to the sport, as well as the quality of their play, is an important metric when investigating ACLR techniques.
      • Longstaffe R.
      • Leiter J.
      • MacDonald P.
      Anterior cruciate ligament injuries in the National Hockey League: Epidemiology and performance impact.
      The lack of this information is illustrated by the present systematic review, where criteria for RTP is not routinely recorded in the included studies. Level of RTP, in terms of professional/elite is recorded, which can be taken as a surrogate of level of performance; however, lack of data on exposure at that level makes interpretation challenging.
      In Stability, for the purpose of the primary outcome results of the RCT, we documented a median time to RTP, of which there was no statistical difference between groups. We are in the process of doing a deeper dive into this area in an attempt to understand level of play and exposure time. This is vitally important, particularly when you are trying to determine whether one operative procedure performs better than another. The addition of LET, for example, may protect the ACL graft and hence allow improved rates of return to sport and reduced graft failure. In contrast, the addition of LET caused a longer time to regain quadriceps strength.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability study.
      This slightly prolonged rehabilitation time may have had an impact on reducing exposure to at risk activities and protecting the ACL graft from re-rupture. Of course, when we looked at time to RTP, we saw very little difference between groups, but clearly further work is required to understand this better.
      Solely looking at RTP criteria between studies also lends itself to bias. Different surgeons and clinics may have very different criteria for RTP. In Stability, we measured isokinetic strength and hop test limb symmetry index to understand functional recovery.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability study.
      However, we did not use that data to determine RTP, as we wished to be able to study the ability of these tests to predict RTP. In our RTP analysis, we will correlate this metric with RTP in an attempt to understand how these criteria may be used in future. However, in practice, many clinics employ different criteria—some may be time based, others focused in reaching specific goals that can be determined via subjective or objective measures of function. Other studies suggest that psychological readiness may be an even more important factor than all of these tests in determining function and therefore hopefully reducing the risk of re-injury.
      • McPherson A.L.
      • Feller J.A.
      • Hewett T.E.
      • Webster K.E.
      Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries.
      Therefore, it is challenging to conclude that a procedure performed in one study is better or worse than a procedure in another study unless similar criteria are used. In Stability, where we had 9 different centers, the return to sport criteria were not set a priori because of the nature of different surgeons and clinics having different criteria in terms of return. We felt this was important to maintain the pragmatic nature of the study design and speaks to the generalizability of the results.
      A further issue is that of the relationship between rotational laxity and performance. A study by Ayeni et al.
      • Ayeni O.R.
      • Chahal M.
      • Tran M.N.
      • Sprague S.
      Pivot shift as an outcome measure for ACL reconstruction: A systematic review.
      observed that there was a positive correlation between a positive pivot shift and reduced patient reported outcomes. The majority of systematic reviews investigating EA of ACLR have not demonstrated a reduction in rotatory laxity to be correlated with patient-reported outcome measures.
      • Devitt B.M.
      • Bell S.W.
      • Ardern C.L.
      • et al.
      The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: A systematic review with meta-analysis and best-evidence synthesis.
      • Hewison C.E.
      • Tran M.N.
      • Kaniki N.
      • Remtulla A.
      • Bryant D.
      • Getgood A.M.
      Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: A systematic review of the literature.
      • Song G.Y.
      • Hong L.
      • Zhang H.
      • Zhang J.
      • Li Y.
      • Feng H.
      Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon.
      Reduced rates of pivot have been reported with EA, yet none of the systematic reviews have observed any differences in subjective International Knee Documentation Committee score. In Stability, we observed no clinically important differences in International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, or ACL quality of life scores at 6, 12, or 24 months postoperatively,
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial.
      with no differences in limb symmetry index at the same time points.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability study.
      Interestingly, the mean limb symmetry index in both groups approximated 90% at 6 months, indicating that RTP would’ve been acceptable at that time point if all of the centers did not also employ a subjective assessment of movement pattern combined with a time-based goal in regard to graft healing.
      This therefore also questions what role EA plays in athletic performance. Does it even have a role in controlling rotation at these later time points and does it matter? Maybe the most important role is to protect the ACL graft during its healing phase, ensuring that minimal strain is placed on the remodeling tissue so that it is able to do its job when asked at the later return to function time points.
      • Engebretsen L.
      • Lew W.D.
      • Lewis J.L.
      • Hunter R.E.
      The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion.
      Ultimately, when coupled with the protective effect that it provides, in terms of reduction in rotatory laxity and reduction in graft failure, it would appear to be a safe and appropriate procedure to perform in individuals wishing to return to sport. This then poses the question—why not perform an extra-articular procedure on everyone? Clearly, as highlighted here, we have many unanswered questions that will take time to investigate and understand. What is most encouraging is that the orthopaedic community is embracing the renaissance of the EA procedure, and that multiple groups continue to focus on understanding data and translating that into their everyday practice for ultimately the same goal—improving patient outcomes.

      Supplementary Data

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